Tuberculosis does not recognize borders

Shobha Shukla, Citizen News Service - CNSIt is time indeed high time to recognize that globally we have today a 1 billion mobile population, (232 million international and 740 million internal migrants) comprising workers, refugees, asylum seekers, and those forced by climate change to move to other regions. The migration process is fraught with risk factors for TB exposure, infection, transmission and poor outcomes due to social determinants of poverty, substance abuse, and migrant unfriendly health services in receiving countries, making migrants a key affected population for TB.
The TB care and control challenges faced by migrant communities are unique. As they are a very mobile population, it is not only difficult to reach them but also difficult to ensure that their TB treatment is not interrupted in between. Also, they are the poorest of all TB patients, and also more discriminated than the local TB population of their new country of residence, which makes matters worse.

Migration is indeed a challenge for TB programmes and also an opportunity to improve some aspects of them. Free access to healthcare systems for immigrants, reorganization of TB control activities and inclusion of community health workers—CHWs- (as well as religious leaders) who speak the language of the migrant community in the receiving country, are crucial to the control of TB in migrants. CHWs help not only in contact tracing but also in reducing stigma, conveying correct information about the disease, helping migrants to navigate the unfamiliar healthcare system through a friendly and rights based approach.

All these things were brought out very clearly during a workshop on “Participatory development of guiding principles for migrant community-driven projects to eliminate TB,” at the ongoing 45th Union World Conference on Lung Health, in Barcelona. Grass roots examples from Barcelona, Norway and other countries reaffirmed the urgent need to have a common international platform to garner political will and resources to understand the social determinants of TB (and other diseases) in migrants and take steps to help them receive appropriate healthcare.

Deliana Garcia, Director of International Projects, Research, and Development for the Migrant Clinicians Network, told Citizen News Service (CNS) that—“There is now a growing recognition of the importance of the side pieces that need to be put in place—rights based social support, language support and cultural support—so that more migrants, who are in need of it, are brought into TB care and control. Biggest barriers in this work are political and economic situations in countries that are senders and recipients of immigrants. We need more guidelines on importance of integrating immigrants into the healthcare systems. We need to remind people that if you keep anyone in your community healthy you keep the entire community healthy.”

Gilles Cesari, currently working with the Global Fund to fight AIDS, Tuberculosis and Malaria (The Global Fund), has been articulating the cause of migrants for a long time. While speaking to CNS he lamented that migrants (both undocumented as well as documented) are often denied access to health care in the recipient country, as they are generally not protected by the social security system of that country. Stigma and discrimination associated with TB further increases their alienation. But at times they are discriminated even within their own country.

Cesari shared with CNS some specific country examples highlighting migrants’ problems. China has a lot of internal migration from rural to urban areas. But strangely, different laws govern these internal migrants and local population. When people move from rural to urban areas they need a special permit from their place of origin to endorse their migration and this is to be shown to health/school authorities of the region to which they have migrated to access these government services. But most of them being illiterate do not know how to get these permits and they remain registered in their native place (where they do have access to healthcare), and are prevented from accessing healthcare and education for children in their new place of stay.

Then again, countries like Singapore and the Gulf States that owe their economic growth to the large number of migrants coming from China, Indonesia, Sri Lanka and India, have scant recognition of their services, and they are denied access to standard healthcare and decent living conditions.

The salaries paid to migrants are also generally much lower than those paid to the citizens of that country. Even though they often migrate in search of greener pastures, their hiring companies bring them as cheap labour to fill the profit coffers of their employers, at the cost of their own health and decent living. This is something, Cesari rightly felt, we all need to fight to end.

Cesari conceded that there is not much data on the extent of TB in migrants. “But small and localised studies indicate very high rates of TB in them as compared to the general population--in New York prevalence of TB in migrants from Vietnam and Indonesia was found to be 10-15 times higher. Poverty, promiscuity (especially in refugee camps where many families live in cramped conditions), and stigma all result in high TB prevalence in migrants”.

He reiterated that marginalizing migrant communities is totally counter productive to TB control in any country. Policies whereby even documented migrants are deported to their parent country (as happens in Singapore and Qatar) when diagnosed with TB, compels them to hide in their community, for fear of deportation by authorities. So instead of seeking treatment in a health centre and not become infectious, they just stay hidden and keep on infecting other people until they cannot take it any more.

Undocumented migrants are even more vulnerable as they have even lesser access to healthcare. Even if they have the money to go to the health centre and pay, they would not do so because they do not have a legal status in that country. So they would rather hide and try to avoid having any contact with any government entity like health centres or TB clinics. All this helps in spreading the TB infection.

Cesari cited the good practice example of South Africa where incidence and prevalence of TB is very high in the migrant miners coming from Zimbabwe, Mozambique, and Botswana as compared to the rest of the population. “Also when these minors go back home they carry with them more TB and less money. So these countries have taken an inspiring initiative of having regional dialogues with mining companies, migrants and local communities. They have come up with an agreement to take care of access to, and continuation of TB treatment of migrants with TB. A referral system also refers the patients from one country to the other to ensure that there is no treatment interruption. The Global fund is also supporting this programme for working together to improve TB treatment adherence.”

Several international organizations like the IOM (international organization for migration), World Health Organization (WHO), The Global Fund and The Union, among others, are working together to address TB in migrants. The new post 2015 global TB strategy of WHO emphasizes upon (i) migrant inclusive National TB programmes; (ii) migrant sensitive care and prevention; and (iii) bold inter-sectoral policies. Cesari hoped that together they would come up with some guidelines of best practices of community driven projects helping migrants access healthcare, especially TB care and treatment.

It is not just the work of the public health professionals in the field of TB, but it is more of a general work to be done in terms of accepting migrants. There is a need to change the way migrants are perceived in order to integrate them with local populations to ensure better healthcare for them.

Shobha Shukla, Citizen News Service (CNS)30 October 2014(The
author is the Managing Editor of Citizen News Service - CNS. She is
supported by the World Health Organization (WHO)'s Global Tuberculosis
Programme to report from the 45th Union World Conference on Lung Health
in Spain. She is a
J2J Fellow of National Press Foundation (NPF) USA and received her
editing training in Singapore. She has earlier worked with State
Planning Institute, UP and taught physics at India's prestigious Loreto
Convent. She also co-authored and edited publications on gender justice,
childhood TB, childhood pneumonia, Hepatitis C Virus and HIV, and
MDR-TB. Email: shobha@citizen-news.org, website: www.citizen-news.org)